Do Experienced Open Surgeons Learn Laparoscopic Colorectal Surgery Faster? A Study for the National Training Program in England

Introduction: It remains unclear to what degree experience in open surgery impacts the learning of the according laparoscopic operation. The aim of this study was to investigate the impact of previous experience in open colorectal resections on the learning rate in laparoscopic colorectal surgery.Methods: Data from the National Training Programme in Laparoscopic Colorectal Surgery in England were split into procedures performed by senior open colorectal surgeons (CRS) and surgical trainees (ST). Patient demographics, case specifications and clinical outcomes were analysed. Case complexity and performance scores were evaluated using a validated task-specific self-assessment form [global assessment score (GAS), range: 1-6]. Nonlinear regression was used to analyze learning curves. Linear regression was used to determine the learning rate in terms of number of cases required to reach a sufficient skill level to perform the case without any substantial support by the trainer (GAS score 5). Results: 1233 supervised, elective operations were analysed. 990 procedures were performed by 119 CRS and 242 cases by 25 ST. There were no differences for patient demographics and case selection. Clinical outcomes were not different between the groups, demonstrated by the rates of conversions (CRS 5.2%, ST 5.8%, p=0.703), complications (13% vs. 12.8%, p=0.91), mortality (0.6% vs. 0.4%, p=0.718) and reoperations (3.5% vs. 3.7%, p=0.899). The self-perceived difficulty of the cases was not different (CRS 3.71, ST 3.83, p=0.273). The overall performance score was significantly higher for the CRS group (4.17 vs. 3.91, p=0.008). There was no difference for generic laparoscopic tasks such as port insertion (p=0.092), however resectional tasks, such as vascular pedicle dissection (p<0.001) or mobilization of the colon (p=0.008) were significantly higher in the CRS group. The learning curve for the ST group was slower than for CRS (see graph). CRS surgeons had a learning rate of 23 cases [15-31 (95% CI)], ST surgeons 36 cases [19-55 (95% CI)].Conclusion: Results suggest that experience in open colorectal surgery increase the self-perceived learning rate for laparoscopic resections in supervised training. Confidence in anatomical landmarks and knowledge of pathological characteristics may be beneficial for the understanding of advanced laparoscopic surgery. Since supervised training is safe and acceptable clinical outcomes can be achieved, there is no need to achieve competency in an open colorectal surgery before embarking on laparoscopic training.